Mission Statement:
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Sports programs your group is involved with:
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*Additional members of your organization to be included in the
membership directory can be included on a separate piece of paper.
Please include contact information.

Method of Payment: ($100)
___Check (payable to the "Michigan Athletes with Disabilities Hall of Fame - ASC")

___Visa   ___Mastercard   ___Discover   ___AMEX

Card Number:__________________________ Exp. Date:___/____

Signature:_____________________________       Vin #: ________

Billing Street Address:_______________________________

City/State/Zip:_____________________________________

*Please include billing address information if different from above.